Protecting Maintaining and Improving the Health of Minnesotans
Certified Mail # 7004 1160 0004 8711 8291
August 18, 2005
Carol Kvidt, Administrator
Bethany Home Health Services
1020 Lark Street
Alexandria, MN 56308
Re: Licensing Follow Up Revisit
Dear Ms. Kvidt:
This is to inform you of the results of a facility visit conducted by staff of the Minnesota Department of
Health, Case Mix Review Program, on July 8, 2005.
The documents checked below are enclosed.
X
Informational Memorandum
Items noted and discussed at the facility visit including status of outstanding licensing correction
orders.
MDH Correction Order and Licensed Survey Form
Correction order(s) issued pursuant to visit of your facility.
Notices Of Assessment For Noncompliance With Correction Orders For Home Care Providers
Feel free to call our office if you have any questions at (651) 215-8703.
Sincerely,
Jean Johnston, Program Manager
Case Mix Review Program
Enclosure(s)
cc:
John Lundblad, President Governing Board
Kelly Crawford, Minnesota Department of Human Services
Douglas County Social Services
Sherilyn Moe, Office of Ombudsman for Older Minnesotans
Case Mix Review File
10/04 FPC1000CMR
ALHCP 2620 Informational Memorandum
Page 1 of 1
Minnesota Department Of Health
Health Policy, Information and Compliance Monitoring Division
Case Mix Review Section
INFORMATIONAL MEMORANDUM
PROVIDER: BETHANY HOME HEALTH SERVICES
DATE OF SURVEY: 07/06/2005
BEDS LICENSED:
HOSP:
NH:
CENSUS:
HOSP:
NH:
BCH:
SLFA:
BCH:
BEDS CERTIFIED:
SNF/18:
SNF 18/19:
ALHCP
SLFB:
SLF:
NFI:
NFII:
ICF/MR:
OTHER:
NAME (S) AND TITLE (S) OF PERSONS INTERVIEWED: Janice Doebber, RN;Brittany
Streng, Resident Assistant.
SUBJECT: Licensing Survey
Licensing Order Follow Up
X
ITEMS NOTED AND DISCUSSE
1)
An unannounced visit was made to followup on the status of state licensing orders issued
as a result of a visit made on December 17, 2004. The results of the survey were
delineated during the exit conference. Refer to Exit Conference Attendance Sheet for the
names of individuals attending the exit conference. The status of the Correction orders is
as follows:
1. MN Rule 4668.0860 Subp. 2
Corrected.
Protecting, Maintaining and Improving the Health of Minnesotans
Certified Mail # 7004 1160 0004 8714 2255
January 2, 2005
Gary Brink, Administrator
Bethany Home Health Services
1020 Lark Street
Alexandria, MN 56308
Re: Licensing Follow Up Revisit
Dear: Mr. Brink
This is to inform you of the results of a facility visit conducted by staff of the Minnesota Department of
Health, Licensing and Certification Program, on (Date).
The documents checked below are enclosed.
X
Informational Memorandum
Items noted and discussed at the facility visit including status of outstanding licensing correction
orders.
X
MDH Correction Order and Licensed Survey Form
Correction order(s) issued pursuant to visit of your facility.
Notices Of Assessment For Noncompliance With Correction Orders For Assisted Living Home
Care Providers
Feel free to call our office if you have any questions at (651) 215-8703.
Sincerely,
Jean Johnston, Program Manager
Case Mix Review Program
Enclosure(s)
Cc, Gary Brink, President Governing Board
Case Mix Review File
Kelly Crawford, Minnesota Department of Human Services
Douglas County Social Services
Sherilyn Moe, Office of Ombudsman
Jocelyn F. Olson, Assistant Attorney General
10/04 FPC1000CMR
ALHCP 2620 Informational Memorandum
Page 1 of 1
Minnesota Department Of Health
Health Policy, Information and Compliance Monitoring Division
Case Mix Review Section
INFORMATIONAL MEMORANDUM
PROVIDER: BETHANY HOME HEALTH SERVICES
DATE OF SURVEY: December 17, 2004
BEDS LICENSED:
HOSP:
NH:
CENSUS:
HOSP:
NH:
BCH:
SLFA:
BCH:
BEDS CERTIFIED:
SNF/18:
SNF 18/19:
ALHCP
SLFB:
SLF:
NFI:
NFII:
ICF/MR:
OTHER:
NAME (S) AND TITLE (S) OF PERSONS INTERVIEWED: Janice Doebber, RN; Shanna
Hubenette, Universal Worker; Rosella Johnson, client.
SUBJECT: Licensing Survey
Licensing Order Follow Up X
ITEMS NOTED AND DISCUSSED
1)
2)
An unannounced visit was made to follow-up on the status of state licensing orders
issued as a result of a visit made on July 19, 20, 23 and 26, 2004. The results of the
survey were delineated during the exit conference. Refer to Exit Conference Attendance
Sheet for the names of individuals attending the exit conference. The status of the
Correction orders is as follows:
1. MN Rule 4668.0800, Subp. 3
Corrected
2. MN Rule 4668.0815, Subp. 2
Corrected
Although a State licensing survey was not due at this time, correction orders were issued.
ALHCP Licensing Survey Form
Page 1 of 5
Assisted Living Home Care Provider
LICENSING SURVEY FORM
Registered nurses from the Minnesota Department of Health (MDH) use the Licensing Survey
Form during an on-site visit to evaluate the care provided by Assisted Living home care
providers (ALHCP). The ALHCP licensee may also use the form to monitor the quality of
services provided to clients at any time. Licensees may use their completed Licensing Survey
Form to help communicate to MDH nurses during an on-site regulatory visit.
During an on-site visit, MDH nurses will interview ALHCP staff, make observations, and review
some of the agency’s documentation. The nurses may also talk to clients and/or their
representatives. This is an opportunity for the licensee to explain to the MDH nurse what
systems are in place to provide Assisted Living services. Completing the Licensing Survey Form
in advance may expedite the survey process.
Licensing requirements listed below are reviewed during a survey. A determination is made
whether the requirements are met or not met for each Indicator of Compliance box. This form
must be used in conjunction with a copy of the ALHCP home care regulations. Any violations of
ALHCP licensing requirements are noted at the end of the survey form.
Name of ALHCP: BETHANY HOME HEALTH SERVICES
HFID # (MDH internal use): 22032
Date(s) of Survey: December 17, 2004
Project # (MDH internal use): QL22032001
Indicators of Compliance
1. The agency only accepts
and retains clients for whom it
can meet the needs as agreed
to in the service plan.
(MN Rules 4668.0050,
4668.0800 Subpart 3,
4668.0815, 4668.0825,
4668.0845, 4668.0865)
Outcomes Observed
Each client has an assessment and
service plan developed by a
registered nurse within 2 weeks and
prior to initiation of delegated nursing
services, reviewed at least annually,
and as needed.
The service plan accurately describes
the client’s needs.
Care is provided as stated in the
service plan.
The client and/or representative
understands what care will be
provided and what it costs.
Comments
Met
Correction
Order(s) issued
Education
provided
Indicators of Compliance
2. Agency staff promotes the
clients’ rights as stated in the
Minnesota Home Care Bill of
Rights.
(MN Statute 144A.44; MN
Rule 4668.0030)
3. The health, safety, and well
being of clients are protected
and promoted.
(MN Statutes 144A.44;
144A.46 Subd. 5(b), 144D.07,
626.557; MN Rules
4668.0065, 4668.0805)
4. The agency has a system to
receive, investigate, and
resolve complaints from its
clients and/or their
representatives.
(MN Rule 4668.0040)
Outcomes Observed
ALHCP Licensing Survey Form
Page 2 of 5
Comments
No violations of the MN Home Care
Bill of Rights (BOR) are noted during
observations, interviews, or review of
the agency’s documentation.
Clients and/or their representatives
receive a copy of the BOR when (or
before) services are initiated.
There is written acknowledgement in
the client’s clinical record to show
that the BOR was received (or why
acknowledgement could not be
obtained).
Clients are free from abuse or neglect.
Clients are free from restraints
imposed for purposes of discipline or
convenience. Agency staff observes
infection control requirements.
There is a system for reporting and
investigating any incidents of
maltreatment.
There is adequate training and
supervision for all staff.
Criminal background checks are
performed as required.
There is a formal system for
complaints.
Clients and/or their representatives
are aware of the complaint system.
Complaints are investigated and
resolved by agency staff.
5. The clients’ confidentiality
is maintained.
(MN Statute 144A.44; MN
Rule 4668.0810)
Client personal information and
records are secure.
Any information about clients is
released only to appropriate parties.
Permission to release information is
obtained, as required, from clients
and/or their representatives.
6. Changes in a client’s
condition are recognized and
acted upon. (MN Rules
4668.0815, 4668.0820,
4668.0825)
A registered nurse is contacted when
there is a change in a client’s
condition that requires a nursing
assessment or reevaluation, a change
in the services and/or there is a
problem with providing services as
stated in the service plan.
Emergency and medical services are
contacted, as needed.
The client and/or representative is
informed when changes occur.
Met
Correction
Order(s) issued
Education
provided
Met
Correction
Order(s) issued
Education
provided
Met
Correction
Order(s) issued
Education
provided
Met
Correction
Order(s) issued
Education
provided
Met
Correction
Order(s) issued
Education
provided
Indicators of Compliance
7. The agency employs (or
contracts with) qualified staff.
(MN Statutes 144D.065;
144A.45, Subd. 5; MN Rules
4668.0070, 4668.0820,
4668.0825, 4668.0030,
4668.0835, 4668.0840)
8. Medications are stored and
administered safely.
(MN Rules 4668.0800
Subpart 3, 4668.0855,
4668.0860)
9. Continuity of care is
promoted for clients who are
discharged from the agency.
(MN Statute 144A.44,
144D.04; MN Rules
4668.0050, 4668.0170,
4668.0800,4668.0870)
10. The agency has a current
license.
(MN Statutes 144D.02,
144D.04, 144D.05, 144A.46;
MN Rule 4668.0012 Subp.17)
Note: MDH will make referrals to
the Attorney General’s office for
violations of MN Statutes 144D or
325F.72; and make other referrals,
as needed.
Outcomes Observed
ALHCP Licensing Survey Form
Page 3 of 5
Comments
Staff has received training and/or
competency evaluations as required,
including training in dementia care, if
applicable.
Nurse licenses are current.
The registered nurse(s) delegates
nursing tasks only to staff who are
competent to perform the procedures
that have been delegated.
The process of delegation and
supervision is clear to all staff and
reflected in their job descriptions.
The agency has a system for the
control of medications.
Staff is trained by a registered nurse
prior to administering medications.
Medications and treatments
administered are ordered by a
prescriber.
Medications are properly labeled.
Medications and treatments are
administered as prescribed.
Medications and treatments
administered are documented.
Clients are given information about
other home care services available, if
needed.
Agency staff follows any Health Care
Declarations of the client.
Clients are given advance notice
when services are terminated by the
ALHCP.
Medications are returned to the client
or properly disposed of at discharge
from a HWS.
The ALHCP license (and other
licenses or registrations as required)
are posted in a place that
communicates to the public what
services may be provided.
The agency operates within its
license(s).
Met
Correction
Order(s) issued
Education
provided
Met
X Correction
Order(s) issued
X Education
provided
N/A
Follow-up #1
Met
Correction
Order(s) issued
Education
provided
N/A
Met
Correction
Order(s) issued
Education
provided
Please note: Although the focus of the licensing survey is the regulations listed in the Indicators of
Compliance boxes above, other violations may be cited depending on what systems a provider has or
fails to have in place and/or the severity of a violation. Also, the results of the focused licensing survey
may result in an expanded survey where additional interviews, observations, and documentation
reviews are conducted.
ALHCP Licensing Survey Form
Page 4 of 5
Survey Results:
All Indicators of Compliance listed above were met.
For Indicators of Compliance not met and/or education provided, list the number, regulation
number, and example(s) of deficient practice noted:
Indicator of
Compliance
Regulation
8
MN Rule 4668.0860 Subp. 2
Prescriber’s orders.
Correction
Order
Issued
X
Followup #1
Education
provided
X
Statement(s) of Deficient Practice/Education:
Based on record review and interview
the licensee failed to have prescriber’s
orders for medications used for two of
four clients (#3 and #4) reviewed who
received assistance with selfadministration of medication or
medication administration. The
findings include:
Client #3’s Service Plan December 8,
2004 indicated that the client was to
receive “medication management and
Reminders I.” The housing with
services contract indicated that
“Medication Management &
Medication Reminders I”, consisted of
“weekly medication set-ups in
medication box in apartment, refills
called to pharmacy, monitoring for side
effects and up to twice a day staff will
verbally remind resident to take
medication.” Client #3 received
medications including Prozac 20 mg,
every morning; Zestoretic 20 12.5mg,
every morning; and ‘1 pain reliever
PM’, every night at bedtime”.
On December 17, 2004, the registered
nurse stated that she had taken the
orders from the prescription bottles’
labels that the client was using on
December 13, 2004 and she was
currently in the process of obtaining
orders from the physician.
Client #4’s Service Plan, October 15,
2004, indicated that the client was to
receive “medication administration.”
“The Medication Administration
Record” indicated that the client had
been receiving medication
administration since October 16, 2004.
ALHCP Licensing Survey Form
Page 5 of 5
Indicator of
Compliance
Regulation
Correction
Order
Issued
Education
provided
Statement(s) of Deficient Practice/Education:
The licensee’s registered nurse stated
on December 17, 2004 that she had
called the clinic on October 15, 2004 to
fax over a current list of medications
the client was receiving. The record
contains a faxed copy of “Chronic
Medication List”, dated October 15,
2004, for the client. The list of
medications included: ASA, 81mg
daily; multivitamin with iron daily;
Diovan 160mg, every day; Atenolol
50mg,twice daily; Buspar 15mg. Two
tablets twice daily; Zoloft 25mg., every
day; Lasix 40mg, every day; KCl 20
meq. one every day and milk of
magnesium, as needed. The physician
had not signed the “Chronic Medication
List”. The facility faxed the physician
an updated medication list that he
signed on November 15, 2004 and
returned to the licensee. On December
17, 2004, the licensee stated that this
signed, faxed copy of the medication
orders was the first physician signed
orders received by the licensee.
Education: Provided.
A draft copy of this completed form was left with Janice Doebber, RN and Patti Carey
at an
exit conference on December 17, 2004. Any correction orders issued as a result of the on-site
visit and the final Licensing Survey Form will arrive by certified mail to the licensee within 3
weeks of this exit conference (see Correction Order form HE-01239-03). If you have any
questions about the Licensing Survey Form or the survey results, please contact the Minnesota
Department of Health, (651) 215-8703. After supervisory review, this form will be posted on the
MDH website. General information about ALHCP is also available on the website:
http://www.health.state.mn.us/divs/fpc/profinfo/cms/alhcp/alhcpsurvey.htm
Regulations can be viewed on the Internet: http://www.revisor.leg.state.mn.us/stats (for MN
statutes) http://www.revisor.leg.state.mn.us/arule/ (for MN Rules).
(Form Revision 7/04)
Protecting, Maintaining and Improving the Health of Minnesotans
Certified Mail # 7003 2260 0000 9988 0668
September 23, 2004
Gary Brink, Administrator
Bethany Home Health Services
1020 Lark Street
Alexandria, MN 56308
Re: Results of State Licensing Survey
Dear Mr. Brink:
The above agency was surveyed on July 19, 20, 23, and 26, 2004 for the purpose of assessing
compliance with state licensing regulations. State licensing deficiencies, if found, are delineated
on the attached Minnesota Department of Health (MDH) correction order form. The correction
order form should be signed and returned to this office when all orders are corrected. We urge
you to review these orders carefully, item by item, and if you find that any of the orders are not
in accordance with your understanding at the time of the exit conference following the survey,
you should immediately contact me, or the RN Program Coordinator. If further clarification is
necessary, I can arrange for an informal conference at which time your questions relating to the
order(s) can be discussed.
A final version of the Licensing Survey Form is enclosed. This document will be posted on the
MDH website.
Also attached is an optional Provider questionnaire, which is a self-mailer, which affords the
provider with an opportunity to give feedback on the survey experience.
Please feel free to call our office with any questions at (651) 215-8703.
Sincerely,
Jean Johnston, Program Manager
Case Mix Review Program
Enclosures
cc: Gary Brink, President Governing Board
Case Mix Review File
CMR 3199 6/04
ALHCP Licensing Survey Form
Page 1 of 6
Assisted Living Home Care Provider
LICENSING SURVEY FORM
Registered nurses from the Minnesota Department of Health (MDH) use the Licensing Survey
Form during an on-site visit to evaluate the care provided by Assisted Living home care
providers (ALHCP). The ALHCP licensee may also use the form to monitor the quality of
services provided to clients at any time. Licensees may use their completed Licensing Survey
Form to help communicate to MDH nurses during an on-site regulatory visit.
During an on-site visit, MDH nurses will interview ALHCP staff, make observations, and review
some of the agency’s documentation. The nurses may also talk to clients and/or their
representatives. This is an opportunity for the licensee to explain to the MDH nurse what
systems are in place to provide Assisted Living services. Completing the Licensing Survey Form
in advance may expedite the survey process.
Licensing requirements listed below are reviewed during a survey. A determination is made
whether the requirements are met or not met for each Indicator of Compliance box. This form
must be used in conjunction with a copy of the ALHCP home care regulations. Any violations of
ALHCP licensing requirements are noted at the end of the survey form.
Name of ALHCP: BETHANY HOME HEALTH SERVICES
HFID # (MDH internal use): 22032
Date(s) of Survey: July 19, 20, 23, and 26, 2004
Project # (MDH internal use): QL22032001
Indicators of Compliance
1. The agency only accepts
and retains clients for whom it
can meet the needs as agreed
to in the service plan.
(MN Rules 4668.0050,
4668.0800 Subpart 3,
4668.0815, 4668.0825,
4668.0845, 4668.0865)
Outcomes Observed
Each client has an assessment and
service plan developed by a
registered nurse within 2 weeks and
prior to initiation of delegated nursing
services, reviewed at least annually,
and as needed.
The service plan accurately describes
the client’s needs.
Care is provided as stated in the
service plan.
The client and/or representative
understands what care will be
provided and what it costs.
Comments
X
X
Met
Correction
Order(s) issued
Education
provided
Indicators of Compliance
2. Agency staff promote the
clients’ rights as stated in the
Minnesota Home Care Bill of
Rights.
(MN Statute 144A.44; MN
Rule 4668.0030)
3. The health, safety, and well
being of clients are protected
and promoted.
(MN Statutes 144A.44;
144A.46 Subd. 5(b), 144D.07,
626.557; MN Rules
4668.0065, 4668.0805)
4. The agency has a system to
receive, investigate, and
resolve complaints from its
clients and/or their
representatives.
(MN Rule 4668.0040)
Outcomes Observed
ALHCP Licensing Survey Form
Page 2 of 6
Comments
No violations of the MN Home Care
Bill of Rights (BOR) are noted during
observations, interviews, or review of
the agency’s documentation.
Clients and/or their representatives
receive a copy of the BOR when (or
before) services are initiated.
There is written acknowledgement in
the client’s clinical record to show
that the BOR was received (or why
acknowledgement could not be
obtained).
Clients are free from abuse or neglect.
Clients are free from restraints
imposed for purposes of discipline or
convenience. Agency staff observe
infection control requirements.
There is a system for reporting and
investigating any incidents of
maltreatment.
There is adequate training and
supervision for all staff.
Criminal background checks are
performed as required.
There is a formal system for
complaints.
Clients and/or their representatives
are aware of the complaint system.
Complaints are investigated and
resolved by agency staff.
5. The clients’ confidentiality
is maintained.
(MN Statute 144A.44; MN
Rule 4668.0810)
Client personal information and
records are secure.
Any information about clients is
released only to appropriate parties.
Permission to release information is
obtained, as required, from clients
and/or their representatives.
6. Changes in a client’s
condition are recognized and
acted upon. (MN Rules
4668.0815, 4668.0820,
4668.0825)
A registered nurse is contacted when
there is a change in a client’s
condition that requires a nursing
assessment or reevaluation, a change
in the services and/or there is a
problem with providing services as
stated in the service plan.
Emergency and medical services are
contacted, as needed.
The client and/or representative is
informed when changes occur.
X
Met
Correction
Order(s) issued
Education
provided
X
Met
Correction
Order(s) issued
Education
provided
X
Met
Correction
Order(s) issued
Education
provided
X
Met
Correction
Order(s) issued
Education
provided
X
X
Met
Correction
Order(s) issued
Education
provided
Indicators of Compliance
7. The agency employs (or
contracts with) qualified staff.
(MN Statute 144D.065; MN
Rules 4668.0070, 4668.0820,
4668.0825, 4668.0030,
4668.0835, 4668.0840)
8. Medications are stored and
administered safely.
(MN Rules 4668.0800
Subpart 3, 4668.0855,
4668.0860)
9. Continuity of care is
promoted for clients who are
discharged from the agency.
(MN Statute 144A.44,
144D.04; MN Rules
4668.0050, 4668.0170,
4668.0800,4668.0870)
10. The agency has a current
license.
(MN Statutes 144D.02,
144D.04, 144D.05, 144A.46;
MN Rule 4668.0012 Subd.17)
Note: MDH will make referrals to
the Attorney General’s office for
violations of MN Statutes 144D or
325F.72; and make other referrals,
as needed.
Outcomes Observed
ALHCP Licensing Survey Form
Page 3 of 6
Comments
Staff have received training and/or
competency evaluations as required,
including training in dementia care, if
applicable.
Nurse licenses are current.
The registered nurse(s) delegates
nursing tasks only to staff who are
competent to perform the procedures
that have been delegated.
The process of delegation and
supervision is clear to all staff and
reflected in their job descriptions.
The agency has a system for the
control of medications.
Staff are trained by a registered nurse
prior to administering medications.
Medications and treatments
administered are ordered by a
prescriber.
Medications are properly labeled.
Medications and treatments are
administered as prescribed.
Medications and treatments
administered are documented.
Clients are given information about
other home care services available, if
needed.
Agency staff follow any Health Care
Declarations of the client.
Clients are given advance notice
when services are terminated by the
ALHCP.
Medications are returned to the client
or properly disposed of at discharge
from a HWS.
The ALHCP license (and other
licenses or registrations as required)
are posted in a place that
communicates to the public what
services may be provided.
The agency operates within its
license(s).
X
Met
Correction
Order(s) issued
Education
provided
X
Met
Correction
Order(s) issued
Education
provided
N/A
X
X
Met
Correction
Order(s) issued
Education
provided
N/A
X
Met
Correction
Order(s) issued
Education
provided
Please note: Although the focus of the licensing survey is the regulations listed in the Indicators of
Compliance boxes above, other violations may be cited depending on what systems a provider has or
fails to have in place and/or the severity of a violation. Also, the results of the focused licensing survey
may result in an expanded survey where additional interviews, observations, and documentation
reviews are conducted.
ALHCP Licensing Survey Form
Page 4 of 6
Survey Results:
All Indicators of Compliance listed above were met.
For Indicators of Compliance not met and/or education provided, list the number, regulation
number, and example(s) of deficient practice noted:
Indicator of
Compliance:
# 1
Regulation:
MN Rule 4668.0800,Subp. 3
Statement(s) of
Deficient Practice:
#1
Based on observation, interview, and record review the licensee did not
provide all the services required by the client’s service plan for one of
three active client records (#1) reviewed.
Client #1’s current service plan, October 2003, indicated that the client
was to have, “a monthly skilled nurse visit, monitoring of exercise and
blood sugars. The latest documented registered nurse (RN) visit was June
30, 2004. The previous skilled nursing visit was April 30, 2004. A
physician order dated October 31, 2003 ordered accu-checks to be done
twice weekly. Client #1’s record had documentation of blood sugar
testing on June 1, 8, 15, 22, 30, and July 16, and 20, 2004. On interview,
July 20, 2004, the RN stated she was unaware that client #1’s service plan
required monthly skilled nursing visits and that she thought the accuchecks were to be done weekly. June 1, 2004 the service plan was
modified with “continue with breakfast preparation, receive noon and
supper meal in dining room and staff to do dishes each AM after
breakfast.” When interviewed July 23, 2004, a direct care staff stated that
they did client #1’s dishes if they had time, which was not every day but
that they did do them at least every Monday on his housekeeping day.
Staff indicated that because the daily log had one line to initial for “
breakfast prep and daily dishes” it was initialed if breakfast prep alone
was completed. During a home visit with interview, Friday July 23, 2004,
client #1 stated that staff clean up his dishes one to two times per week
and sometimes he does them himself. While visiting, this reviewer
observed his kitchen sink stacked full of dishes. When interviewed, July
23, 2004, the RN stated that she had informed the staff that they were to
do his breakfast preparation and clean-up daily. She said and the
“Resident Services Delivery Records” indicated that staff have been
initialing daily from July 1, 2004 to the present (July 23, 2004) that Lester
is receiving “Breakfast prep and dishes-daily”.
Education: #1
X
X
Correction Order Issued
Education provided
Education was provided on the need to provide services as stated in the
service plan.
ALHCP Licensing Survey Form
Page 5 of 6
Correction Order Issued
X
Education provided
Indicator of
Compliance:
# 1
Regulation:
MN Rule 4668.0815,Subp. 4
Contents of Service Plan
Education: #1
The service plan on client #1 lacked the fees for services. The service
plan had been modified February 2004 and June 2004 without evidence of
change in fees. The service plan stated that the payer source was
“Douglas County PH”. Client #1 stated that he could not remember that
he had seen the fees for services or informed of them. On July 23, 2004
education was provided to the registered nurse and Manager on the need
to have the fees in the service plan and authenticated by the licensee and
client and updated with modifications. The Administrator was also
educated on this on this requirement on exit day.
Indicator of
Compliance:
# 6
MN Rule 4668.0815,Subp. 2
Revaluation of Service Plan
Statement(s) of
Deficient Practice:
#6
Based on observation, interview, and record review the licensee did not
have the registered nurse (RN) review and revise a service plan when
there was a change in client condition for one of three active client
records (#2) reviewed.
Education #6
X
X
Correction Order Issued
Education provided
The April 2004 service plan for client #2 indicated services to be
provided included medication administration and monitoring of blood
sugars. The May 12 through May 18, 2004 medication administration
record (MAR) indicated insulin that of to be administered at 8:30PM
there were four syringes of Lantus, and ten syringes of Humalog insulin,
to be administered before meals, left in the resident’s refrigerator, unused.
According to the service plan and RN supervisory notes of April 26, 2004
and June 24, 2004, staff was to observe the client taking her medications
including injecting her insulin. A physician’s order, May 4, 2004, stated
to monitor blood sugars before breakfast and supper. Client #2’s care plan
stated she preferred to check blood sugars herself. The agency provides
staffing from 7am to 8pm daily. If medications are to be taken later than
8pm the agency does not have staff on duty to observe the administration
of medication. During home visits with interviews July 23, and July 26,
2004, it was observed that client #2 had not been recording her blood
sugars twice daily and had missed recording any on several days. Client
#2 stated, “I’m so forgetful and I don’t always remember to check my
blood sugar.” When interviewed July 20, 2004 two universal workers
stated the client was often in another client’s room visiting. When client
#2 was not in her room they stated they left her medications including
insulin in her room with a note. Both stated they were unaware of the care
plan change directing staff “must observe her injections of insulin and
ingest oral medications.” On July 26, 2004, the RN stated that she “was
not aware that resident was failing to check her blood sugars as ordered.”
Rule reviewed with nurse and limitation of service agency provides.
ALHCP Licensing Survey Form
Page 6 of 6
Correction Order Issued
X
Education provided
Indicator of
Compliance:
# NA
Regulation:
CLIA Waiver
Other Education:
Licensee provides assistance with glucose monitoring with client’s own
monitoring device. CLIA waiver required. Administrator unable to find
waiver. He will apply for one. Education provided on need for waiver
when assisting with glucose monitoring.
A draft copy of this completed form was left with Gary Brink, Administrator
at an
exit conference on July 26, 2004. Any correction orders issued as a result of the on-site visit and
the final Licensing Survey Form will arrive by certified mail to the licensee within 3 weeks of
this exit conference (see Correction Order form HE-01239-03). If you have any questions about
the Licensing Survey Form or the survey results, please contact the Minnesota Department of
Health, (651) 215-8703. After supervisory review, this form will be posted on the MDH website.
General information about ALHCP is also available on the website:
http://www.health.state.mn.us/divs/fpc/profinfo/cms/alhcp/alhcpsurvey.htm
Regulations can be viewed on the Internet: http://www.revisor.leg.state.mn.us/stats (for MN
statutes) http://www.revisor.leg.state.mn.us/arule/ (for MN Rules).
(Form Revision 7/04)